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Policy Number LCH-105

This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form.Part A – Information about this DocumentPolicy Name Guidelines Growth Monitoring in Children Aged 0-5 YearsPolicy Type Board Approved (Trust-wide) ☐ Trust-wide ☐ Divisional / Team / Locality ☒

Action No Change ☐ Minor

Change ☐ MajorChange ☐ New

Policy ☒ No LongerNeeded ☐

Approval

As Mersey Care’s Executive Director / Lead for this document, I confirm that this document:a) complies with the latest statutory / regulatory requirements,b) complies with the latest national guidance,c) has been updated to reflect the requirements of clinicians and officers, andd) has been updated to reflect any local contractual requirements

Signature: Date:Part B – Changes in Terminology (used with ‘Minor Change’, ‘Major Changes’ & ‘New Policy’ only)

Terminology used in this Document New terminology when reading this Document

Part C – Additional Information Added (to be used with ‘Major Changes’ only)Section /

Paragraph NoOutline of the information that has been added to this document – especially where it may

change what staff need to do

Part D – Rationale (to be used with ‘New Policy’ & ‘Policy No Longer Required’ only)Please explain why this new document needs to be adopted or why this document is no longer required

Part E – Oversight Arrangements (to be used with ‘New Policy’ only)Accountable Director

Recommending Committee

Approving Committee

Next Review Date

LCH Policy Alignment Process – Form 1

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SUPPORTING STATEMENTS This document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESSAll Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: being alert to the possibility of child / adult abuse and neglect through their observation of

abuse, or by professional judgement made as a result of information gathered about the child / adult;

knowing how to deal with a disclosure or allegation of child / adult abuse; undertaking training as appropriate for their role and keeping themselves updated; being aware of and following the local policies and procedures they need to follow if they

have a child / adult concern; ensuring appropriate advice and support is accessed either from managers, Safeguarding

Ambassadors or the trust’s safeguarding team; participating in multi-agency working to safeguard the child or adult (if appropriate to your

role); ensuring contemporaneous records are kept at all times and record keeping is in strict

adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;

ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session

EQUALITY AND HUMAN RIGHTSMersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.

The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.

Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.

Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy

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Liverpool Community Health NHS Trust

Guidelines for growth monitoring in children aged 0-5 years

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Version Number: One

Guideline Reference Number: 105

Ratified by: Clinical Standards Group

Date of Approval: 21st February 2017

Name of originator/author: Monica ClarksonAnita Carter

Approving Body / Committee: Clinical Standards Group

Date issued (Current version): April 2017

Review date (Current Version): February 2018

Target Audience: All staff who work with or come into contact

with mothers andName of Lead Director / Managing Director:

Director of Nursing

Changes / Alterations Made ToPrevious Version:

Version One

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Contents

Section1 Introduction

Page4

2 Aims and Objectives 5

3 Purpose 5

4 Definitions 5

5 Roles and Responsibilities 6

6 When to Weigh and Measure 7

Stepwise approach to poor weight gain and feeding7 9

difficulties

Stepwise approach to excessive weight gain and8 10

feeding difficulties

Normal growth patterns and deviation from normal

9 patterns: Key points identified by Royal College of

Paediatrics and Child Health (RCPCH) 11

10 Consultation approval and ratification 12

Dissemination and Implementation 12

Document control 12

11 Process for Monitoring Compliance and effectiveness 12

12 References 13

AppendicesNICE and RCPCH guidance when to weigh and

Appendix A

Appendix B

14measure

Feeding Assessments

• Breastfeeding under six months of age15

• Bottle feeding under six months of age

• Babies aged over six months

Appendix C Calculating percentage weight loss 21

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INTRODUCTION

Childhood growth:

Growth is an important indicator of a child’s health and wellbeing. Poor growth in utero and in early childhood is associated with short and long term health issues. These include increased rates of childhood infection and the development of lifestyle diseases, for example, coronary heart disease, high blood pressure and diabetes. Childhood growth is significantly influenced by a variety of genetic, biological and environmental factors. See figure one.

Faltering Growth:

95% of faltering growth is not related to disease but is most commonly caused by under nutrition with multi factorial causes, often involving problems with diet and feeding behaviour that usually responds to targeted advice. It is rarely associated with neglect, maternal health problems or addiction (Shields 2012). Faltering growth occurs across all socio-economic groups:

• Faltering growth occurs because children receive insufficient calories• Dividing faltering growth into two categories - non-organic and organic is misleading,

they are not mutually exclusive• Most cases of faltering growth do not have organic causes

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• Many children have a range of intrusive and inappropriate medical tests to eliminate organic causes

• Only a tiny minority of children fail to grow because of neglect or abuse• Emotional deprivation is not a major reason for faltering growth• Difficulties with feeding are the most commonly cited factor involved in faltering

growth (Children’s Society and Community Practitioner and Health VisitorAssociation 2016).

Click on the link below for more detail:h tt p : / / ww w . g p - t r aining . n e t / t r aining /t u t o r ial s / c lini c a l/ paedia t r i c s / p g r o w t h2 . h t m

Liverpool Community Health (LCH) Health Visiting Service is ideally placed to identify and assess risks at an early stage and provide information, support and referral for families. The UK- World Health Organization (WHO) growth charts which are present in the Parent Held Personal Child Health record (PCHR) provide a standard to monitor growth.

It is important to note that over nutrition and obesity are also linked with poor health outcomes. Both infant body size and infant growth velocity during the early years of life are associated with the risk of later overweight and obesity in childhood and adulthood. The WHO has identified that worldwide obesity has more than doubled since 1980.

AimTo provide a stepwise approach to managing feeding difficulties, poor weight gain and excessive weight gain in infants and children during the delivery of the Healthy Child Programme by the LCH Health Visiting Service.

Objectives:

To provide guidance for the Health Visiting teams regarding:• A minimum standard for when children should be weighed and measured• Early interventions to prevent poor weight gain• Early interventions to prevent excessive weight gain

PurposeTo ensure that all staff employed by LCH understand their role and responsibilities in supporting expectant mothers, new mothers and their partners and carers to feed and care for their infants /children in ways which support optimal health and wellbeing.

DefinitionsThe following definitions have been agreed and adopted as workable definitions for use within LCH.

Faltering Growth: This term is used to cover other commonly used terms to describe poor growth including failure to thrive, growth faltering, or poor nourishment (National Institute for Clinical Excellence).

Learning Disability: A significant reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with; a reduced ability to cope independently (impaired social functioning); which started before adulthood, with a lasting effect on development (DH 2001).

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Responsibilities

It is the responsibility of the Health Visitor to ensure that the growth of all children under 5 years old is monitored. The equipment, techniques and methods of recording and plotting in the fact sheets and growth charts produced by the Royal College of Paediatrics and Child Health (RCPCH) should be used as listed below:

• Fact sheet for parents• Fact sheet 1 what are growth charts• Fact sheet 2 what is the difference• Fact sheet 3 measuring and plotting• Fact sheet 4 new-born infants• Fact sheet 5 preterm infants• Fact sheet 6 infants and toddlers• Fact sheet 7 low birth weight charts• GP summary 10 things to know about the UK –WHO growth charts

RCPCH h tt p : / / ww w . rc p c h . a c . u k / c hild - heal t h / r e s e a rc h - p r o j e c t s / u k - w ho - g r o w t h -c ha r t s / u k - w ho - g r o w t h -c ha r t - r e s ou r c e s- 0 - 4 - y ea rs / u k- w ho -0

Measuring and assessing the growth of young children should be carried out by a member of staff who has been trained by the Health Visitor using the equipment, techniques and methods specified by the RCPCH.

Weight, height and head circumference should be recorded and plotted in the PCHR using the appropriate UK-WHO 2009 centile charts (RCPCH) and recorded in the child’s electronic record.

Children with Down’s syndrome and Turners syndrome should have their measurements plotted on the appropriate WHO UK growth charts.

If a practitioner has any concerns about parental understanding of the advice, support and guidance given related to basic care, feeding or safety of their child then this should be discussed with the parent/carer. The practitioner should seek advice, support and guidance from their line manager and if there are safeguarding concerns this should be discussed with the Safeguarding Children’s Team. The parents should be offered help with regards to Early Help Assessment. It should be ascertained if the parent/ carer has existing support or an advocate to ensure, with the parents’ consent, the appropriate information is shared with them.

To support equality in health outcomes and safeguard children, all staff must make reasonable adjustments to their practice and implement extra support for parents and carers who have identified special needs as required. This includes parents with a learning disability, impairment, or sensory loss (Equality Act 2010). Staff should also be aware of and implement appropriate measures to support those with cultural and language differences. Appropriate support should be based on the communication and learning needs identified by the service user, their family carer or health professional. For example by offering support from: a British Sign Language (BSL) interpreter, deafblind manual interpreter, language interpreter or an advocate.

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If an individual practitioner has concerns that their client has difficulty understanding or is unable to develop the skills required to care for their child they should further assess mental capacity including discussion of their concerns with the family doctor or the Mental capacity act coordinator for LCH. The LCH Mental Capacity Act Policy is available via the following link:

h tt p : / / ope r a . li v e r pool c h . nh s . u k / S I RS / Poli c ie s- and - P r o c edu r e s / Clini c al % 20Poli c ie s / M CA % 20Poli c y . p d f

The client’s information or communication needs and how they should be met must be flagged on the child’s electronic record in the section for managed patient warnings.

h tt p : / / ope r a . li v e r pool c h . nh s . u k / S I RS / Poli c ie s- and - P r o c edu r e s / Co r p o r a t e % 20Poli c ie s / Re c o r d s % 2 0 M anu a l % 20Poli c y . pd f

Delegation of responsibility

The Health Visitor has continuing responsibility and is accountable to ensure that any task delegated to non-registered staff adheres to the principles of:The NMC Code of professional standards of practice and behaviour for nurses and midwives 2015Standard 11 states:Be accountable for your decisions to delegate tasks and duties to other people To achieve this, you must:

11.1 only delegate tasks and duties that are within the other person’s scope of competence, making sure that they fully understand your instructions11.2 make sure that everyone you delegate tasks to is adequately supervised and supportedso they can provide safe and compassionate care, and11.3 confirm that the outcome of any task you have delegated to someone else meets the required standard.

The LCH Health Visiting teams have staff with different qualifications and skills to deliver the Healthy Child Programme. All members of staff have a responsibility to access appropriate training and work within their sphere of competence and accountability as outlined within their job description. The 2 year review can be delegated to a member of the skill mix team when the family are receiving the Universal Healthy Child Programme. Child health clinics can also be delegated to members of the skill mix team.

The Community Staff Nurses or Nursery Nurses who work within the Health Visiting teams must report deviations from normal growth patterns and the proposed actions agreed with the family to the Health Visitor. The Health Visitor should support the Nursery Nurse/ Community Staff Nurse to complete a full feeding assessment and follow the stepwise approach to feeding difficulties, poor weight gain and excessive weight gain, and refer if necessary. This discussion and agreed actions should be documented by both parties in the child’s electronic record.When families are receiving a higher level of service i.e. universal plus and universal partnership plus, the review should normally be completed by the Health Visitor or in partnership with the Community Staff Nurse/Nursery Nurse. This can be negotiated in line with the NMC code (2015) taking into account the principles of delegation and accountability.

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Liverpool Community Health Guidelines

When to weigh and measure

The LCH Health Visiting Service is not commissioned to provide universal contacts at all of the stages when NICE, and the RCPCH recommend the routine weighing and measuring of children (See Appendix A). However, Health Visitors should advise families of the RCPCH guidelines which are outlined in the PCHR.

The healthy child home visiting programme provided by the LCH Health Visiting Service provides a series of opportunities to assess feeding and measure the growth of all children.

All children should be weighed and measured at all Universal Healthy Child Programme contacts and at any other contacts where a concern regarding the child’s growth has been raised.

If there is any concern regarding the rate of growth the Health Visitor should:• Complete a full feeding assessment (Appendix B)• Follow the stepwise approach to feeding difficulties and poor weight gain (Figure 2)• Follow the stepwise approach to feeding difficulties and excessive weight gain

(Figure 3).

1. BIRTH VISIT (10-14 days) weight

• Health Visitor to complete a full feeding assessment and weigh the baby as part of the holistic birth assessment. Details of this assessment (including weight), the care given and any resulting action plan should be recorded in the child’s electronic records. This will provide baseline data for future monitoring

• If the baby has been weighed at 10 days by the Midwife, the Health Visitor must ensure that the weight and centile is recorded in the PCHR and on the child’s electronic record, with a note that the baby was weighed by the midwife and at what age. NICE guidelines recommend babies should be weighed at 5 and 10 days by the Midwifery Service (NICE 2011)

• If the baby’s weight is still below the birth weight the percentage weight loss must be calculated to aid assessment (Appendix C how to calculate % weight loss)

• If weight loss is 10% or over the Health Visitor must liaise with the midwife to agree who will refer for medical follow up (this is only seen in 1:50 babies)

• If weight loss is under 10% but the baby has still not regained its birth weight, the Health Visitor must agree an action plan with the family and arrange a date for further contact to monitor progress. All actions should be agreed and discussed with parents and documented in the PCHR and child’s electronic record.

2. BIRTH FOLLOW UP VISIT (4-8 weeks) weight, length and head circumference

• Health Visitor to complete weight, length and head circumference measurement. Plot on appropriate section of growth chart in PCHR and record in the child’s electronic record

• If there is any concern regarding the rate of growth, the Health Visitor should complete a full feeding assessment and follow the stepwise approach to feeding difficulties, poor weight gain and excessive weight gain and refer if necessary

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• All actions should be agreed and discussed with parents and documented in the child’s electronic record.

3. 1 YEAR REVIEW (9-12 months) weight, length and head circumference

• Health Visitor to complete weight, length and head circumference measurementand plot in the appropriate section on the growth chart in the PCHR and record in the child’s electronic record

• If there is any concern regarding the rate of growth, the Health Visitor should complete a full feeding assessment and follow the stepwise approach to feeding difficulties, poor weight gain and excessive weight gain and refer if necessary

• All actions should be agreed and discussed with parents and documented in child’s electronic record.

4. 2 YEAR REVIEW (2 years to 2 years six months) weight, height and BMI (Please see above re delegation of tasks)

• Health Visitor or a member of the skill mix team to complete a weight and height measurement and plot in the appropriate section on growth chart in PCHR and the child’s electronic record

• If there is any concern regarding the rate of growth, the Health Visitor must complete a Body Mass Index measurement (BMI), a full feeding assessment and follow the stepwise approach to feeding difficulties, poor weight gain and excessive weight gain and refer if necessary

• All actions should be agreed and discussed with parents and documented in PCHR and in the child’s electronic record.

Note: Local arrangements can be made to invite families to attend well baby clinics in

advance of the Universal Healthy Child Programme assessments so that these

measurements can be taken in the clinic environment and recorded on the child’s electronic

record in preparation for the assessment.

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Figure 2: Stepwise Approach to Poor Weight Gain and Feeding Difficulties

PreventionUniversal Healthy Child Programme Assessments: Routine weighing and measuring at these contacts as a minimum intervention as per LCH Guidelines.

Professional/parental concernsIssues identified by Health Visitor, parent or by RCPCH guidelines on expected weight gain and feeding difficulties.

Early Intervention: Poor weight gain (less than 2 centile spaces variation) or identified feeding problem. No symptoms of organic illness. (Weight usually tracks within one centile space but individual measurements often show wide variation RCPCH).1. Repeat full feeding assessment; See Appendix B for enhanced feeding assessment and care plan advice2. Develop and agree a care plan with parents/carers including follow up3. Health Visitor to consider referral for: tongue tie division, dietician, speech and language therapists, psychology

and/or safeguarding team based on identified need4. Advice re opportunities for ongoing routine assessment and weighing in the community5. Signpost to appropriate community resources for enhanced support.

Weight loss greater than 10% of birth weight at birth visit: (This is only seen in 1:50 babies)1. Repeat full feeding assessment; see Appendix B

for enhanced feeding assessment and care plan advice

2. Develop and agree action plan with parents/carers.

Faltering Growth Intervention: Poor weight gain showing a sustained drop through 2 or more centile spaces in an otherwise well child. (This is displayed by less than 2% of infants on UK- WHO growth charts).1. Repeat full feeding assessment; see Appendix B for

enhanced feeding assessment and care plan advice2. Develop and agree action plan with parents/carers.

Urgent liaison with midwife to agree appropriate medical referral.

G.P completes a medical examination and refers for appropriate medical investigations.

1. Illness identified and managed by the appropriate specialist service to prevent under nutrition.2. No symptoms of organic illness (95% of cases BMJ 2012).

Health Visitor continues to monitor growth and provide advice regarding diet and feeding problems to prevent under nutrition.

SafeguardingIf any issues are identified which are a cause for concern that a child’s safety is at risk, all staff must follow local safeguarding procedures, ensuring all appropriate referrals and documentation are evidenced in the child’s electronic record.

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Figure 3: Stepwise Approach to Excessive Weight Gain and Feeding Difficulties

PreventionUniversal Healthy Child Programme Assessments: Routine weighing and measuring at these contacts as a minimum intervention as per LCH Guidelines.

Professional/parental concernsIssues identified by Health Visitor, parent or by RCPCH guidelines on expected weight gain and feeding difficulties.

Early Intervention: Excessive weight gain (less than 2 centile spaces variation) or identified feeding problem. No symptoms of organic illness. (Weight usually tracks within one centile space but individual measurements often show wide variation RCPCH).1. Repeat full feeding assessment; See Appendix B for enhanced feeding assessment and care plan advice2. For a child 2 years of age onwards, the Health Visitor must complete a Body Mass Index measurement (BMI) and a

full feeding assessment3. Develop and agree a care plan with parents/carers including follow up4. Health Visitor to consider referral for: dietician, psychology and/or safeguarding team based on identified need5. Advice re opportunities for ongoing routine assessment and weighing in the community6. Signpost to appropriate community resources for enhanced support.

Excessive Weight Gain Intervention: Excessive weight gain showing a sustained rise through 2 or more centile spaces in an otherwise well child.1. Repeat full feeding assessment; see Appendix B for enhanced feeding assessment and care plan advice2. Develop and agree action plan with parents/carers.

G.P completes a medical examination and refers for appropriate medical investigations.

1. Illness identified and managed by the appropriate specialist service to prevent over nutrition.2. No symptoms of organic illness (95% of cases BMJ 2012).

Health Visitor continues to monitor growth and provide advice regarding diet and feeding problems to prevent over nutrition.

SafeguardingIf any issues are identified which are a cause for concern that a child’s safety is at risk, all staff must follow local safeguarding procedures, ensuring all appropriate referrals and documentation are evidenced in the child’s electronic record.

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Normal growth patterns and deviation from normal patterns: Key points identified by the RCPCH (For more detailed information see WHO –UK Growth charts

fact sheets)

Because children grow at varying rates at different ages and along different tracks, we can only understand whether a measurement is normal by comparing it with the normal range of measurements for other children of the same age and gender. This is what the growth charts allow us to do (RCPCH fact sheet 1).

Plotting and assessing New-born Infants (RCPCH fact sheet 4)• Most babies lose some weight after birth• 80% of babies have regained their birth weight by the age of two weeks• Recovery of birthweight therefore helps to provide assurance that feeding is effective

and that the child is well• Only I in 50 babies (fewer than 5%) are 10% or more below their birth weight at two

weeks of age• Any child who has not regained their birthweight at this stage should have their %

weight loss calculated (see Appendix C: how to calculate % weight loss)• Weight loss of 10% or more needs careful assessment for feeding problems and/or

unrecognised illness e.g. cardiac disorder or inherited metabolic disorder.

Plotting and assessing infants and toddlers up to age four years (RCPCH fact sheet 6)What is a normal rate of weight gain?

• Centile charts are not intended to look at single weight but to measure progressive weight patterns (RCPCH)

• Weight usually tracks within one centile space but individual measurements often show wide variation

• Acute illness- weight loss and weight centile fall which usually returns to normal within two to three weeks

• Less than 2%of infants will show a sustained drop through two or more weight centile spaces on the RCPCH-WHO charts

• These children should be assessed by the primary care team including measuring length/ Height.

What is a normal rate of growth?• Length/height should be measured when there is a concern about weight gain,

growth or development• Measurements commonly show wide variation• Measurements can be made on a few occasions if worried to see if there is an

average centile over time• Healthy children tend to show a stable general pattern over time• If there appears to be a consistent change in centile by more than one space then

the child should be assessed in more detail.

What is a normal rate of head growth?• Head circumference usually tracks within one centile space• Fewer than 1% of infants drop or rise through more than two centile spaces after the

first few weeks

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• If this occurs these children should be carefully assessed. Very rapid head growth can indicate conditions such as hydrocephalus while slowing of head growth may be a sign of underlying problems with brain or skull growth.

When should a single measurement trigger assessment?There is no single threshold below or above which a child’s weight is definitely abnormal Further assess:

• All children with measurements below 0.4th centile• Children with height above the 99.6th centile plus other concerns• If weight above 99.6th centile after age two look up BMI centile.

Interpreting Body Mass Index (BMI)• A child whose weight is average for their height will have a BMI between the 25th and

75th centiles whatever their height centile• A BMI above the 91st centile suggests the child is overweight• BMI above the 98th centile is very overweight (clinically obese)• BMI below the 2nd centile is unusual and may reflect under nutrition but can also be

seen in children with unusual body shapes, particularly if they have chronic illness ordisability.

Consultation Approval and Ratification

As author of these guidelines the Infant Feeding Coordinator consulted with the Sefton multi agency infant feeding group and the Liverpool Infant Feeding Champions Group. This guideline will be reviewed and revised 3 yearly in line with the trust policy or earlier if changes in legislation or evidence dictate.

Dissemination and implementation

The LCH Infant Feeding Coordinator shall forward the ratified guidelines and the completed implementation plan to the LCH Clinical Governance Department. The department is the central point for administering all policies and maintains the data base of policies and organisation wide procedures on the performance accelerator.

Document ControlThe clinical governance department will be responsible for storing current and archiving out of date guidelines.

Monitoring Compliance with and effectiveness of the guidelines

Compliance with the policy will be monitored by:

A minimum annual audit measuring the experience of both breast and bottle feeding families which will be measured using the UNICEF UK Baby Friendly Initiative audit tools recommended for breast and bottle fed babies 2013.

Audit results will be reported to the lead staff for children’s services in all localities across Sefton and Liverpool and an action plan will be agreed by the local managers to address any areas of non-compliance that have been identified. The results and the action plan will be presented to staff at local meetings.

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References

Children’s Society and CPHVA (February 2016) Clinical Tutorialsh tt p : / / ww w . g p - t r aining . n e t / t r aining /t u t o r ial s / c lini c a l/ paedia t r i c s / p g r o w t h2 . h t m

Department of Health March 2001: Valuing People: A new strategy for Learning Disability for the 21st century

Government Western Australia Child and Antenatal manual (2014): Factors which influence childhood growth

NICE Guidance (2011): Postnatal care up to 8 weeks after birthh tt p s : / / ww w . ni c e . o r g . u k / g uidan c e / c g 37?unlid = 83890046201692615413 4

NMC (2015) Code of professional standards of practice and behaviour for nurses and midwives

RCPCH Early years WHO UK growth charts and resources (updated August 2016) h tt p : / / ww w . rc p c h . a c . u k / c hild - heal t h / r e s e a rc h - p r oje c t s / u k- w ho - g r o w t h -c ha r t s / u k- w ho - g r o w t h - c ha r t -r e s o u rc e s - 0 - 4 - y ea rs / u k - w ho -0

Shields BMJ (September 2012) Weight faltering and failure to thrive in infancy and early childhood

WHO fact sheets (updated June 2016)h tt p : / / ww w . w ho . in t/m edi a c en t r e / f a c t s he e t s / f s 31 1 / en /

WHO physical activity and children (accessed August 2016)h tt p : / / ww w . w ho . in t/ die t p hy s i c ala c ti v i t y / c hildhood / e n /

WHO Childhood obesity (accessed August 2016)h tt p : / / ww w . noo . o r g . u k / N OO _abo u t _obe s i t y / c hil d _obe s i t y

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Appendix A

NICE Guidance for when to weigh and measure (2011)

“As a minimum, ensure babies are weighed (naked) at birth and at 5 and 10 days, as part of an overall assessment of feeding. Thereafter, healthy babies should be weighed (naked) no more than fortnightly and then at 2, 3, 4 and 8 to 10 months in their first year”

h tt ps : / / w w w . g u i de l i ne . go v / su mm a r i e s / su m m a r y / 1247 9

RCPCH When to weigh and measure (2009)

Well babies should be weighed and measured no more than:

• Once per month before six months• Once per 2 months aged 6-12 months• Once per 3 months over the age of one year

Head Circumference length or height should be measured:

• Whenever there are any worries about a child’s weight gain, growth or general health• If the weight is below the 0.4th centile• If there is very rapid weight gain• If the weight is above the 99.6th centile• If the child is over two calculate BMI to help tell whether the child is relatively over or

under weight

In addition, head circumference should be measured:

• Around birth• At the eight week check• At any time after that if there are worries about the child’s head growth or

development

h tt p : / / ww w . rc p c h . a c . u k / g r o w t h c ha r t s

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Appendix B

Breastfeeding: Assessment for babies under six months of age

*Tongue tieTongue ties become less of a problem as baby grows. However, in some babies a tongue tie which was not causing problems in the early days can begin to create a problem when the amount of milk needed is increasing. The extra effort to suck may be tiring the baby out.

**Early introduction of solid foods before six monthsBreastfed babies: Early introduction of solid foods before six months will result in a reduced intake of the calorie rich breastmilk. Commonly recommended first foods are calorie poor and may not effectively maintain weight gain. Mothers should be advised of this so that they can make the decision to stop/reduce solids and increase their breastfeeding before their body adjusts to the lower demand.

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Breastfeeding

To increase milk supply.

Day One1. Complete a full breastfeeding assessment.

2. Observe a full breastfeed to check for effective position and attachment and effective milk transfer.

3. Check baby for signs of tongue tie*.

4. Advise increasing skin to skin contact to stimulate milk production.

5. Ensure mother is aware of how to recognise effective feeding including the beginning middle and end of the feed and regular swallowing.

6. Advise that both breasts should be offered at each feed.

7. Recommend a minimum of 10-12 feeds per 24 hours with no more than one 4-6 hour break in any 24 hour period. Emphasise the importance of night feeds to increase milk supply.

8. Advise re how dummies can mask feeding cues and delay feeds.

9. Check for early introduction of solid foods and advise re reasons why this is not recommended**.

10. Advise re community support available in area.

Day Two (24 hours)

Review for early signs of increased milk intake/ milk production in both baby and mother. Baby- Particularly an increase in urine and faeces output to at least 6 heavy wet nappies and two dirty ones yellow soft and runny size of a £2 coin/ 24 hours.Mother- full breasts.

If signs satisfactory review in 48 Hours on Day Four.If not reiterate all elements of the care plan and review in 24 hours.

Day Three (36 hours)

Review for signs of increased milk intake/production.If signs satisfactory review in 48 Hours Day Five for weight gain.If not reiterate all elements of the care plan and review in 24 hours.

Day Four (48 hours)If there is no weight gain then consideration to supplementation is required.

Day Five (72 hours)

Review babies who were showing signs of increased milk intake on Day Three (36 hours).

If there is no weight gain then consideration to supplementation with formula milk is requiredas there is currently no availability of donor breastmilk for this difficulty.

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Formula Feeding: Assessment for babies under six months of age

Surname Firstname Date of birth

Address

NHS number Health Visitor

Bottle FeedingAssessment

Effective feeding (E) Advice required (A) E A

How feeds are madeup

Parents following manufacturer’s directions for sterilising equipment.

Pre-boiled tap water used over 70ºc.

Measure water into bottle first then milkpowder using manufacturer’s scoopand levelled as recommended. The correct number of scoops tovolume of water measured.

Incorrectly sterilised equipment can lead to vomiting and diarrhoea.

Mineral water can lead to dehydration.

Over concentration or under-concentration of milk can create problems including dehydration, reflux and can impact on weight gain.Diluted feeds should never be used forany children.

Feeding cues Baby fed in response to early cues Crying is a late feeding cue and baby may need to be calmed to feed effectively. Excessive dummy use may be masking feeding cues.

How baby is held forfeeding

Head, shoulders, hips and feet in alignment with the bottle baby cuddled into carer and slightly more upright than a breast fed baby able to make eyecontact

Skin contact and close contact increase Oxytocin levels making feeding a pleasurable rather than stressful experience. Position slightly to the right side will aid

Paced feeding Encourage rooting.Invite baby to take the teat. Pace the feed.Never force a ‘full’ feed.Limit who gives the feeds.

If baby is held flat and not secure then stress levels will increase.

Feeding Equipment Read and follow manufacturer’s instructions using all parts from samefeeding system.Three common types of system• vented by anti-vacuum skirt on teat• vented by a tube• collapsible plastic bag

Although they may appear to fit together the anti-vacuum skirt of teats from one systemmay not work with bottles from anothersystem.

Teats

Different shaped teats

Flow rate of teat

Baby sucks from teat calmly no milk escapes, no vacuum builds up andcarer provides breaks during feeds inresponse to baby cues.Some mums may find one type of teat better than another.

Milk escaping mouth and dribbling during feed.

Baby getting frustrated during feed or creating a vacuum with the teat.

No evidence to support any specific marketing claims.Try slower flow rate and check for tongue tie.

Is the ring holding the teat screwed on too tight preventing the anti-vacuum skirt from working effectively?

Try faster flow rate.Milk temperature Test for temperature on inside of arm to

avoid the risk of burning the baby’sSome babies are fine with milk at room temperature while others cope better with

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mouth.This is a risk from using microwaves to warm milk.

milk nearer to body temperature. This should be investigated and can help with reflux.

Feeding frequency Frequency of feeds adjusted to meet baby needs. Some babies need smaller more frequent feeds and the amount taken at each feed may vary.

The amount of milk taken over 24 hours rather than milk taken at individual feeds is a better guide to intake.

Appearance andFrequency of stools

A more formed stool with less stools passed in a day than a breastfed baby.

Breastmilk is a natural laxative so constipation is a risk for formula fed babies, so further advice is needed if babies are showing signs of constipation.

Date assessment completed: Health Professional designation: name:signature:

Formula feeding

Complete a full bottle feeding assessment

Observe a full formula feed including how parents make up a bottle of formula

Check baby for signs of tongue tie*

Advise how dummies can mask feeding cues and delay feeds

Advise parents how to hold baby for feeding particularly if any reflux/vomiting

Check for early introduction of solid foods and advise of reasons this is not recommended**

Advise re availability of community support in the area

Follow the link below for: First Steps Nutrition Trust “Infant milks a simple guide to formula, follow formula and other infant milks”

h tt p : // f i r s t s t ep s nu t r i t ion . o r g / p d f s / I n f a n t _ m il k s _a_ s i m ple_ g uide_E n g land_F e b16 . p d f

The First Steps Nutrition Trust works with a number of organisations and networks, all of whom have the same ambition:“to provide accurate information, protect infant and young child feeding and work

independently of commercial influence”. Follow the link for the website which contains a number of evidence based publications on Infant and young child feeding Including the only independent information on “Infant milks in the UK”.

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h tt p : // f i r s t s t ep s nu t r i t ion . o r g /

*Tongue tie

Tongue ties become less of a problem as baby grows. However, in some babies a tongue tie which was not causing problems in the early days can begin to create a problem when the amount of milk needed is increasing. The extra effort to suck may be tiring the baby out.

**Early introduction of solid foods before six months In Formula fed babies

Formula fed babies: Early introduction of solid foods in formula fed babies more commonly leads to an overall increase in calorie intake because parents tend to persist with feeding until their baby takes the “full feed”. However, this may not always be the case and it can potentially lead to a decrease in milk intake with a corresponding decrease in calorie intake. Families should be advised of the higher calorific value of milk feeds and that formula milk is manufactured to contain all the nutrition their baby needs until they are six months old.

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Babies over six months: mixed feeding

Surname First name Date of birth

Address

NHS number Health Visitor

Effective Feeding E Advice required A

Breast/bottlefeeding

Assess as required Advise as required

Self-feeding Child allowed to develop self -feeding skills in safe environment.

Family prepared for mess

Carer controlled spoon feeding.Discuss development of self-feeding skills and how to recognise fullness cues to prevent increasing feeding battles and food refusal

Eatingenvironment

Appropriate place to sit and eat freeof distractions with appropriate adult interaction e.g. adult eats as well

Family not prioritising time for sittingdown to eat together. Discus learning eating skills and social skills

Types of food Range of foods offered from thefive food groups appropriate to child’s age and development

Limited range of foods and limitedopportunities to eat being offered. Discuss diet based on food diary.

Drinks offered Water offered both with andbetween meals

Discuss problems associated withregular consumption of fizzy drinks squash or smoothies

Milk offered Continued breastfeeding with solidfoods offered appropriate to age. Intake of formula milk decreasing as intake of solid food increases

Excessive intake of formula/ cow’smilk or milk products compared to foods from other food groups. Use first steps nutrition trust guidance

Snack intake Snacks appropriate to age Poor mealtime eating due to constantgrazing, high calorie snacks or inappropriately timed snacks

Social Factors Small number of carers who areable to coordinate feeding needs well between them

Discuss solutions to the challengesof communication and the constraints from different carers, nursery’s, childminders etc.

Family Support Family support readily available Promote the support available e.g.children’s and healthy living centres

Healthy Start andother benefits

Family have had advice aboutbenefits, and use healthy start vouchers for wide range of foods

Discuss support available for:Benefits advicecook and stay sessions

Major life events Family and social situation settled Discuss support to cope with

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stresses

Gastro Intestinalsymptoms

Increasing self-feeding controllingown appetite

Discuss development of self-feedingto control intake and fullness cues Vomiting, reflux refer GP

Stools Intake of food from five food groupsappropriate to age. No symptoms of constipation

GP Constipation- discuss dietarymanagement and refer to GP if required

Date assessment completed: Health Professional designation: name:signature:

Babies over six months: mixed feeding

• Discuss parental concerns

• Discuss child’s position on growth chart

• Discuss recent medical history

• Discuss family history of feeding or growth problems e.g. genetic, medical, dietary, social

• Discuss any relevant history that may impact on child e.g. environment, parenting capacity, family members with dietary issues

• Discuss any referral to specialist services

Development of action plan

1. Ask parents to keep a food and drink diary for one week to aid assessment

2. Observe a full meal

3. Advise re: Healthy Start vitamin supplements

4. Advise re community support available in area

5. Resources to support discussions of diet:

Start for life website and leaflets

h t t p : // w w w . nh s . u k / s t a r t 4 li f e / c hoo s ing - f i r s t- f ood s

LCH “ Guide to Introducing Solid Foods from Six Months- Key messages on Infant Nutrition”

LCH “Healthy Eating for toddlers Health Professionals’ guide

First Steps Nutrition Trust and Healthy Start Alliance website for information in Infants and New mums section and eating well early years section h tt p : // f i r s t s t ep s nu t r i t ion . o r g /

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Appendix C

Calculating percentage weight loss

Percentage weight loss is the difference between the actual weight and the weight at birthexpressed as a percentage of birth weight

How to calculate percentage weight loss:

birth weight in kg - current weight in kg = weight loss in kg

weight loss in kg ÷ birth weight in kg x100% = percentage weight loss

For example:birth weight 2.900 kg - current weight 2.700kg = weight loss 0.20 kg (a fall of 200 grams)

w e i g h t lo ss O. 2 kg x 100% = percentage weight loss 6.89% birth weight 2.9 kg